What is the appropriate management for a person of any age who has ingested a poison?

Treatment of Poison Ingestion for All Ages

Contact your regional poison control center immediately (1-800-222-1222 in the US) while simultaneously initiating stabilization—this is the single most critical action for any suspected poisoning regardless of the substance or patient age. 1, 2, 3, 4, 5

Immediate Priorities (First 5 Minutes)

Ensure Scene and Provider Safety

• Never contaminate yourself during decontamination—assess for hazardous chemicals, toxic fumes, or corrosive substances before approaching the patient 1, 2
• Wear appropriate protective equipment including gloves when handling contaminated clothing or body fluids 1
• Remove yourself and the patient from environments with toxic gases (hydrogen cyanide, hydrogen sulfide) 1

Stabilization Protocol

• Focus on airway, breathing, and circulation—establish and maintain vital functions with standard life support measures 1, 3, 5
• Assess for life-threatening signs: altered mental status, seizures, respiratory depression, hypotension, or cardiac dysrhythmias 5, 6
• Obtain electrocardiography for chest pain, dyspnea, or suspected overdose of beta-blockers, tricyclic antidepressants, calcium channel blockers, or antidysrhythmics 5
• Measure electrolytes, serum creatinine, bicarbonate, and calculate anion gap based on clinical presentation 5

Decontamination Strategy

What NOT to Do (Critical Contraindications)

• Do NOT induce vomiting with syrup of ipecac—this is contraindicated and provides no benefit while potentially causing aspiration 1, 2, 4, 7
• Do NOT administer anything by mouth unless specifically directed by poison control 1, 2, 3, 4
• Do NOT delay emergency transport to attempt home interventions 4
• Do NOT administer water or milk for dilution unless poison control specifically recommends it 4

Appropriate Decontamination

• Remove all contaminated clothing and jewelry immediately to prevent continued absorption 2, 3
• Brush off any powdered chemicals with a gloved hand before washing 2
• Wash skin thoroughly with soap and water after removing dry chemicals 2, 3
• Irrigate eyes immediately with copious tepid water for at least 15 minutes for any ocular exposure 2, 3

Activated Charcoal Considerations

• Activated charcoal (1 g/kg via small-bore nasogastric tube) may be administered only if specifically recommended by poison control and only within 1-2 hours of ingestion 8, 9
• Do NOT administer activated charcoal at home—this should only be done by healthcare professionals in appropriate settings 7, 9
• Do NOT delay transportation to administer activated charcoal 9

Antidote Administration

When Antidotes Are Indicated

The 2023 American Heart Association guidelines provide specific antidote dosing for life-threatening poisonings 1:

Opioid Poisoning:

• Naloxone 0.2-2 mg IV/IO/IM for adults; 0.1 mg/kg for children 1
• Intranasal naloxone 2-4 mg, repeat every 2-3 minutes as needed 1
• If combined opioid and benzodiazepine poisoning is suspected, administer naloxone first before other antidotes 1
• Titrate to reversal of respiratory depression and restoration of protective airway reflexes, not full consciousness 1

Benzodiazepine Poisoning:

• Flumazenil 0.2 mg titrated up to 1 mg (adults); 0.01 mg/kg (children) can be effective in select patients with pure benzodiazepine poisoning who have respiratory depression and no contraindications 1
• Flumazenil is contraindicated in patients at risk for seizures (chronic benzodiazepine use, tricyclic antidepressant co-ingestion, seizure history) or dysrhythmias 1
• Flumazenil has no role in cardiac arrest from benzodiazepine poisoning 1

Organophosphate/Carbamate Insecticide Poisoning:

• Atropine 1-2 mg for adults; up to 0.1 mg/kg for children (substantially higher than typical pediatric doses) 2
• Do NOT stop atropine in the presence of tachycardia in children—repeated boluses do not cause cardiac arrhythmias in pediatric patients 2
• Pralidoxime 1-2 g for adults; 20-50 mg/kg for children, followed by continuous infusion 1
• Treat seizures with diazepam 0.2 mg/kg or midazolam 0.1 mg/kg, repeated until complete cessation 2
• Monitor for intermediate syndrome at 24-96 hours (respiratory muscle weakness occurs in 19% of patients) 2

Calcium Channel Blocker/Beta-Blocker Poisoning:

• Calcium chloride 1-2 g (adults); 20 mg/kg (children) 1
• Glucagon 2-10 mg (adults); 0.05-0.15 mg/kg (children), followed by continuous infusion 1
• High-dose insulin 1 U/kg bolus followed by 1-10 U/kg/h infusion with dextrose supplementation 1

Cyanide Poisoning:

• Sodium nitrite 300 mg (adults); 6 mg/kg (children)—watch for hypotension 1
• Sodium thiosulfate 12.5 g (adults); 250 mg/kg (children) 1
• Hydroxocobalamin 5 g (adults); 70 mg/kg (children) 1

Sodium Channel Blocker Poisoning (tricyclic antidepressants, cocaine):

• Sodium bicarbonate 50-150 mEq bolus (adults); 1-3 mEq/kg (children), followed by continuous infusion to maintain pH 7.45-7.55 1
• Monitor for hypernatremia, alkalemia, hypokalemia, and hypochloremia 1

Special Considerations by Age

Pediatric Patients (<6 years)

• Acetaminophen: Refer to emergency department if ingestion ≥200 mg/kg or amount unknown 8
• Highest rates of poison exposure occur in children ≤5 years, though most deaths occur in young adults from opioids 5
• Children develop convulsions more frequently due to rapid hypoxia from respiratory muscle weakness in organophosphate poisoning 2

Adults and Adolescents (≥6 years)

• Acetaminophen: Refer to emergency department if ingestion ≥10 g or ≥200 mg/kg (whichever is lower) 8
• Obtain serum acetaminophen level at 4 hours post-ingestion or as soon as possible thereafter 8

Disposition Decisions

Immediate Emergency Department Referral Required

• Any stated or suspected self-harm or malicious poisoning regardless of amount 8, 9
• Signs consistent with poisoning: repeated vomiting, altered mental status, seizures, respiratory depression, hypotension, or cardiac dysrhythmias 5, 8
• Unknown ingestion amount or substance 8, 6
• Ingestion of potentially lethal dose based on poison control guidance 8, 9

Home Observation Acceptable

• Asymptomatic patients >4 hours post-ingestion of known non-toxic dose 9
• Requires poison center-initiated follow-up every 2 hours for specified duration based on substance 9
• Patient must have reliable caregiver and immediate access to emergency services 7

Common Pitfalls to Avoid

• Do not assume benign course based on initial presentation—many poisonings have delayed toxicity (acetaminophen, extended-release formulations, organophosphates) 2, 8
• Do not rely solely on toxidromes—their usefulness is limited when multiple substances are ingested 5
• Do not stop monitoring at 4 hours—intermediate syndrome from organophosphates occurs at 24-96 hours 2
• Do not administer flumazenil empirically—it causes harm in patients with seizure risk or chronic benzodiazepine use 1